YTT Application Form Step 1 of 4 25% Program Dates: July 3-16 and August 11-21, 2018 All fields marked * must be completed before the form can be submitted. Part I: Application Name* First Last Do you have a middle name?* Yes No Middle Name* Email* Phone (Day)*Please follow this format:(888)888-8888Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Date of Birth* YYYY MM DD Please use format yyyy/mm/ddGender*FemaleMaleHow did you hear about us?*[Select]Friend/Relative/Yoga TeacherInternet SearchBeen to the Centre BeforeOtherPlease provide details and/or any comments that will let us know more about how we reached you:Emergency Contact InformationContact Name* First Last Relationship with ContactContact Phone*Contact Email* Allergies & DietWe offer a lacto-vegetarian yogic diet. Please list all dietary allergies that require medical attention and their severity (ingesting vs. being in contact). Also please list any additional dietary concerns or intolerances. While we do our best to provide options, we cannot guarantee that all restrictions can be accommodated.Please list any special dietary needs or indicate "None". Provide full details for food allergies including severity of reactions and precautionary measures taken:*Accommodation & Tuition FeesAccommodation First Choice*[Select]Commuter ($4,361.64)Camping w/ Own Tent ($4,704.96)Camping w/ Centre Tent ($4,943.22)Shared Room w/ Shared Bath ($5,892.05)Shared Room w/ Private Bath ($6,323.84)Private Room w/ Shared Bath ($6,426.68)Fees quoted include all applicable taxesAccommodation Second Choice*[Select]Commuter ($4,361.64)Camping w/ Own Tent ($4,704.96)Camping w/ Centre Tent ($4,943.22)Shared Room w/ Shared Bath ($5,892.05)Shared Room w/ Private Bath ($6,323.84)Private Room w/ Shared Bath ($6,426.68)Fees quoted include all applicable taxes Total Fees = Tuition + Accommodation + Payment Plan Fee + Taxes Total fees and taxes will be confirmed in the student contract and payment plan addendum which will be sent to you after acceptance.Payment Plan - see details below*No payment plan requiredPayment Plan A ($52.50 fee)Payment Plan B ($105.00 fee) Payment Plan A $50 Application fee $450 Upon acceptance $700 June 1st, 2018 Remainder payable in four equal monthly payments commencing July 1, 2018. Payment Plan B $50 Application fee $450 Upon acceptance $700 June 1st, 2018 Remainder payable in seven equal monthly payments commencing July 1, 2018. Students who choose a payment plan will receive their Certificate of Completion when all payments under the plan have been received. Please note that students on a payment plan will be subject to additional administrative charges for any missed payments.A fee of $50 is due before the application process can be completed. This fee will be refunded if you are not accepted and will be applied to your fees if you are accepted. Once we have received your application fee you will be emailed shortly to confirm your acceptance into the program. Within 1-2 weeks you will receive your student contract which should to be signed and returned with a payment of $450 to reserve your space in the program. The remainder of all fees are due by June 1, 2018 unless you have chosen a payment plan. Rates are quoted in Canadian dollars and are subject to all applicable taxes. Part II: QuestionnairePlease answer the following questions about your yoga experience.Describe your previous experience with yoga. Have you completed other teacher training courses? With whom have you studied, for how long, and in what style?*Have you practiced meditation and/or pranayama? Describe your experience.*Describe your current yoga practice. What does it consist of? Does it include pranayama and meditation or just asana? Do you have a home practice or take classes?*Have you ever participated in an intensive residential training course of any kind before? If so, please describe your experience.*Have you studied anatomy/physiology or ayurveda?*Briefly describe any other body/mind or spiritual practices you have been involved with, other than yoga.What do you want to gain from this program?*Are you currently teaching yoga?* No Yes If you answered yes, please tell us where you are teaching, how often, etc.Do you plan on teaching professionally in the future?*YesNoNot sure yetWhat is your current occupation?*Do you have any additional comments regarding your yoga background? Part III: Medical HistoryAll information provided will be kept strictly confidential.Please check any of the following conditions that apply (past or present):* Pregnancy Diabetes - Type 1 Diabetes - Type 2 Coronary Heart Disease Epilepsy Hypertension Asthma or Respiratory Restrictions Anemia Gatro-intestinal & Digestive Disorders (Crohn's, IBS, etc) Autoimmune Disorders (Chronic Fatigue, Rheum Arthritis, etc.) Gynecological Disorders Neurological Disorders & Symptoms (nerve pain, numbness, etc.) Cancer Depression Bipolar OCD or other anxiety disorder Seizures Chemical Dependency (nicotine, alcohol, or other drugs) Eating Disorders (anorexia, bulimia) Sleeping Difficulties Chronic Constipation Allergies Glaucoma Other No medical conditions If you checked any of the conditions above, please provide any relevant details.*Have you suffered any severe shock or ongoing stress in the past year (eg, bereavement, miscarriage, divorce, loss of job, etc.)*YesNoIf yes, please explain:Are there any other issues we should be aware of?If you do have a medical condition, please describe how it is being managed. Include forms of treatment you are following. It is important to include ALL prescribed medications (including anti-depressants, birth control or hormone replacement, anti-histamines).If you have a medical condition, please describe: a) how that affects or modifies your practice of yoga, and b) how living in a residential community may affect your medical condition. Are there any other comments you'd like to add to your application?Application Fee* Price: $ 50.00 CAD Upon submitting this form you will be redirected to Paypal to pay online. Once payment is received an email will be sent to you confirming that we have received your application and payment. You will then be redirected back to our site. If you wish to phone in your credit card information, please call us at 250.537.2326. We also accept Canadian or US cheques and/or money orders. Payments in US funds will be credited toward program fees at the prevailing exchange rate.Yoga Instruction and Liability Waiver and Release* I have read and understood the Yoga Instruction and Liability Waiver and Release and agree to its terms. Cancellation Policy* I have read the Salt Spring Centre's Cancellation Policy and agree to its terms. Centre Guidelines* I have read and agree to the Centre's Guidelines.